Anorexia nervosa: Our health care colleagues are starving amid COVID-19 pandemic

Myth: Severe eating disorders don’t affect health care providers, or HCPs.

Reality: HCPs can and do suffer from severe eating disorders. COVID-19 and its attendant stressors appear to be exacerbating these issues in some HCPs, who have either recovered from an eating disorder or are living with one now.

In my career, I have cared for more than 100 HCPs with severe eating disorders; after all, the disease tends to impact the best and the brightest minds. In the last year, however, there has been an upward trend in the number of HCPs admitted to the ACUTE Center for Eating Disorders & Severe Malnutrition, a unit I founded at Denver Health Medical Center that is singularly dedicated to providing critical care medical stabilization for patients with the most extreme forms of eating disorders. ACUTE treats patients who are extremely ill, with BMIs less than 13 or less than 70% of their ideal body weight. To underscore just how sick ACUTE’s patients are, last year alone, eight people died from their medical issues as their families were in the final stages of planning travel to ACUTE in Denver. Many patients admit on the brink of death.

In December 2020 — arguably at the height of the COVID-19 pandemic — 30% of ACUTE admissions were HCPs, including nurses, physicians, physician assistants, a medical student, a pharmacist and a physical therapist. Even as the vaccine rollout and general pandemic outlook improves into 2021, HCPs continue to arrive to ACUTE by air ambulance from all over the United States and account for up to one-third of ACUTE’s unit at any given time. Prior to the onset of COVID-19, HCPs represented a steady 5% of patients at ACUTE.

I’m a scientist and not prone to assumption. That said, I think about my own experience as a frontline medical provider during COVID-19, and I wonder whether the punishing, invalidating environment of health care in the past year may have triggered — or worsened — eating disorders in the health care heroes whom we have had the honor of caring for on our unit. Regardless of causation, it’s a clarion call to all providers to ensure we are equipped with information, screening criteria and treatment resources to help our colleagues and patients touched by these pernicious illnesses. The emerging literature clearly demonstrates an increased prevalence of eating disorders because of COVID-19.

Anorexia nervosa (AN) is a mental disorder manifested by marked food restrictions, resulting in a very thin body habitus, an abnormal focus on body image and a litany of medical complications that progress as the malnutrition worsens. No body system is immune from the ravages of AN.

During my medical school career, I was never exposed to a patient with AN, nor do I recall any lectures or teachings on it during medical school or residency. Yet, by chance I happened upon a patient with severe AN over 30 ago and have since been deeply involved in the topical area of the medical complications of AN. Sadly, training on the medical nuances of AN and safe refeeding for severely low-weight patients is not standard in medical training curricula. As a result, many vulnerable patients with AN come to harm in hospital settings.

The prevalence of AN is increasing. Currently, the lifetime prevalence is 1.4% for women and 0.2% for men. AN is highly prevalent in younger populations, with 75% of those with AN developing the disease before age 23. AN is significantly comorbid with many other DSM-5 disorders, including depression, obsessive compulsive disorder and generalized anxiety disorder. In fact, the risk for suicide is elevated sixfold in AN, and suicide plus the medical complications associated with AN are the two causes of death that account for the bulk of the marked elevated mortality risk in AN, notwithstanding the young age of these patients. In fact, AN continues to have the highest mortality rate of any psychiatric disorder, aside from the opioid epidemic.

Etiologic factors for AN are not completely distinct. Rather, there exists a complex interplay of different risk factors, including biological vulnerabilities/genetic predisposition; environmental factors such as Western society’s extreme focus on thinness; verbal and sexual abuse; individuation (ie, starting medical school); parental tension; bullying; and the onset of comorbidities like depression and anxiety. Across many different populations, studies have found moderate to high heritability for AN. In addition, there are inherent shared environmental influences that contribute to the risk for AN. The main one is related to the aforementioned idealization of thinness in women. Thus, although genetic influences contribute to the risk, the actualization of AN is culture bound — ie, the gene-environment correlation, or the venerable nature-nature paradigm. Conversely, proactive programs, whose aim is to focus on reducing thin-ideal internalization or thinness expectations, have resulted in demonstratable reductions in disordered eating symptoms.

Additionally, there are certain personality traits that seem to have relevance to the development of AN. This is scientifically plausible since personality traits have been shown to be heritable. Two of the more notable traits include negative emotionality/neuroticism. These are trait-based proclivities toward experiencing unpleasant emotions such as anxiety and anger. The second is the trait of perfectionism via its propensity to cause increases in the drive for thinness and overvaluation of weight and body shape. Certainly, medical providers are a group wherein these personality traits may be overly expressed, which in part may explain their interest in medicine and their successful life journey leading to a career in health care. This confluence of factors, along with possible dopaminergic aberrations in the setting of the stressors of HCPs — which have certainly been exacerbated during COVID-19 — place these individuals at risk for the development of AN or its recrudescence.

AN is associated with numerous medical complications that can affect every organ system in the body. These complications are directly related to the excessive weight loss and caloric restriction that define AN-R (restrictive subtype), and may include:

• Serum chemistry complications, including hypophosphatemia, which may occur due to the anabolic state that ensues as refeeding begins. Multiple recognized metabolic processes begin with refeeding that result in a decrease in serum phosphorous levels. If not treated promptly, critical hypophosphatemia can lead to the highly dangerous refeeding syndrome. The refeeding syndrome is defined by the pentad of rhabdomyolysis, heart failure, respiratory failure, hemolysis and seizures.
• Cardiopulmonary abnormalities are frequently seen in AN-R. Mitral valve prolapse can occur due to a loss of supporting tissues in the heart from weight loss, which can result in chest pain and heart palpitations. Sinus bradycardia is the most common arrhythmia in a patient with AN and is likely from a physiological adaptation that occurs in the setting of malnutrition. There is an increased risk for sudden cardiac death seen in AN-R, thought due to increased QT interval dispersion and lack of heart rate variability. Corrected QT prolongation was previously thought to be inherent to AN, but this has been disproven. Reduction in cardiac output may occur secondary to a reduction in ventricular mass, which can lead to fatigue and dyspnea or from a stress cardiomyopathy. Spontaneous pneumothorax, spontaneous pneumomediastinum, and emphysema-like changes can occur in AN, although rarely.
• Global endocrine dysregulation due to the body’s adaptation to the low-energy state seen with chronic starvation is another complication of AN. This has deleterious consequences on skeletal health, with potentially permanently reduced bone mineral density (BMD), impaired bone quality and increased lifelong fragility fracture risk. Decreased BMD can occur relatively rapidly in AN, with changes often apparent after less than 1 year of disease duration. Nonthyroidal illness syndrome is seen, along with an acquired state of growth hormone resistance. Disruption in the hypothalamic-pituitary axis also includes functional hypogonadotropic hypogonadism, which can very often result in amenorrhea. A weight loss of 10% to 15% below ideal body weight will disrupt menstruation in most women. While some studies have demonstrated small increased risk for long-term infertility in AN, even with recovery, unintended pregnancy is actually more of a worrisome issue in AN than in the general population as ovulation can still occur in the absence of menstruation. There is also an increased risk for miscarriage, preterm birth, cesarean section, small for gestational age infants, and microcephaly if conception occurs in a patient with active AN.
• GI complaints are especially frequent in AN, affecting more than 90% of patients. These include postprandial fullness, early satiety, abdominal distention, pain and nausea. GI alterations in AN can be seen throughout the entire GI tract. Weakened pharyngeal muscles can lead to difficulty swallowing, coughing during meals and aspiration. Delayed gastric emptying (gastroparesis) can lead to acute gastric dilation, gastric necrosis and gastric rupture. Superior mesenteric artery (SMA) syndrome is also known to occur with more severe degrees of AN as a result of atrophy of the fat pad that usually secures the position of the SMA away from the aorta. This abnormal ability of the SMA to now move medially traps the duodenum between the SMA and aorta, causing a mechanical small bowel obstruction, and it manifests with abnormal pain that begins soon after commencing to eat. Up to two-thirds of patients with AN suffer from delayed colonic transit and 40% from pelvic floor dysfunction associated with constipation, urinary retention or incontinence.
• Liver function, specifically elevations in aspartate aminotransferase and alanine aminotransferase, can occur as a manifestation of prolonged starvation (autophagy) and with the development of steatosis early in the refeeding process if there is excessive fat and carbohydrate content in the diet composition.
• Anemia, leukopenia and thrombocytopenia are also seen in AN. This is thought to be due to gelatinous marrow transformation, a process of morphologic changes with deposition of a gelatinous mucopolysaccharide that replaces the normal fat of the bone marrow.

AN is a disease shrouded in shame and secrecy. This population of patients tries hard to hide weight loss by wearing bulky clothes and often uses the ED rather than primary care for urgent medical issues. HCPs specifically may avoid or delay treatment due to embarrassment about their inability manage their medical and psychiatric issues. During the COVID-19 pandemic, HCPs may feel obligated to deliver care to their patients (if not themselves), and they may want to show up for their profession in this crisis; they took an oath, and they don’t want to abandon their coworkers.

By avoiding treatment, however, patients with AN become so ill that they require ACUTE’s specialized medical stabilization and weight restoration to survive. Further evidence that patients are waiting longer to seek treatment: Before COVID-19, 16% of patients arrived at ACUTE via air ambulance. At one point during the pandemic, as many as 60% of patients arrived via air ambulance.

AN is a debilitating and often chronic illness that is common in young individuals; however, AN can occur — or recur — at any stage of life. Perhaps one-half of those afflicted will experience a sustained recovery. Efficacious, rigorously proven treatment is therefore important but lacking. A very recent review paints a somewhat pessimistic outlook regarding the efficacy of current psychological treatments for AN. Certainly, reputable residential and inpatient eating disorder treatment facilities exist and should be accessed by those with more serious forms of the illness. Although the right modality of psychotherapy is unclear at this time, the evidence base is clear on effective medical management of the complications that arise from AN.

To summarize, the prevalence of AN was on the rise in the U.S., even before the difficult realities of COVID-19 abruptly changed the health care landscape. To better support health care heroes who are putting their patients and coworkers ahead of their own physical and mental health, we must raise awareness of the sinister medical peril that AN can wrought. In the end, AN is a potentially curable illness, and one that is worth the resources and effort to treat safely and effectively.

References:

Fichter MM, et al. Int J Eat Disord. 2005;doi:10.1002/eat.20215.

Galmiche M, et al. Am J Clin Nutr. 2019;doi:10.1093/ajcn/nqy342.

Schalla MA, et al. Eur Eat Disord Rev. 2019;doi:10.1002/erv.2679.

Murray SB, et al. Psychol Med. 2019;doi:10.1017/S0033291718002088.

Nutley SK, et al. JMIR Ment Health. 2021;doi:10.2196/26011.